Safety of nursing professionals and patient facing COVID-19 pandemic in critical care unit

Abstract Objective: to evaluate nursing professionals and patient safety culture during the professional performance in the care of suspected or infected patients with COVID-19. Method: a cross-sectional study carried out with 90 professionals from critical care units of two teaching hospitals. An instrument for sociodemographic characterization and health conditions was used, in addition to the constructs “Nursing professional and patient safety” and the Hospital Survey on Patient Safety Culture. Univariate analyzes were performed between the diagnosis of COVID-19 and the characteristics of Nursing professionals, applying Kendell’s correlation between the constructs. Results: the COVID-19 diagnosis presented a significant statistical difference between nursing professionals that worked for more than six years at the critical care unit (p=0.020) and the items of the construct “Nursing professional and patient safety” regarding the doubts about how to remove the personal protective equipment (p=0.013) and safety flow (p=0,021). The dimensions 2 (p=0.003), 3 (p=0.009), 4 (p=0.013), 6 (p<0.001), and 9 (p=0.024) of the Hospital Survey on Patient Safety Culture were associated with the accomplishment of training. Conclusion: a higher professional nursing experience time was associated with non-infection by COVID-19. The perception of the safety culture of the patient was related to the accomplishment of training.


Introduction
Experiencing a pandemic has several negative consequences, especially for nursing, a workforce that is at the forefront of hospital care. For these professionals, the development of new functions during the pandemic adds to the responsibilities of comprehensive care of managers and team leaders, in decision-making management, forecasting and provision of equipment and materials, implementing control and prevention strategies in health care, among others. These attributions were decisive for the nursing team, whose responsibility is to value their own safety and that of the patient as one of the fundamental pillars of quality in the provision of safe care (1)(2)(3) .
The pressure of the pandemic scenario, many times with the continuous improvement of good safety and communication practices (3)(4)(5)(6) .
During the COVID-19 pandemic, nursing was exposed to: work overload, high virus transmissibility, manipulation of specific protective equipment and high technology, which led health team members to physical and mental exhaustion in the workplace experienced worldwide (7) .
Thus, the attitudes of nursing professionals, their training, the availability and safe use of PPE, psychological followup, peer support and workload influence workers in this area regarding the assessment of the safety of patients who were hospitalized. during the COVID-19 pandemic (8) .
In this context, the present study carried out in two teaching hospitals in different Brazilian states, had as objective to evaluate nursing professionals and patient safety culture during the professional performance in the care of suspected or infected patients with COVID-19.

Method Study design
This is an exploratory cross-sectional study carried out in critical care units (prompt care, Intensive Care Unit (ICU)/semi-intensive and surgical center), guided by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) (9) tool.  (10) . Strongly agree, aiming to attribute a numerical value to the given answers by the participants according to the level of agreement with the statements.

Setting and sample size of the study
We elaborated the construct "Professional and patient safety" and we submitted to face and content validity in 2020. For that, a committee composed of three nurses specialized in nursing management, patient security and infection control and prevention related to the health care thematic evaluated the construct for validation. We invited the specialists to participate in the validation through an invitation letter sent via email with the ICF. They analyzed the instrument items regarding the content (relevance of the items in the instrument) and adequacy to measure with clarity what needs it proposes to measure (face validity). It was considered the level of agreement of 80% among the judges for each item to be evaluated (11) .
We carried out the validation phase of the construct at  to the dimension X (we will exclude positive, neutral, and negative from missing data)] x 100 (10) .
We collected sociodemographic data and COVID-19 data from nursing professionals. The categorical variables

Data analysis
We carried out the analysis of the sociodemographic data and COVID-19 infection through descriptive statistics using the R 4.1.1 software. We carried out descriptive statistics for every variable aiming at the overall characterization of the sample. We described the qualitative variables through absolute and relative frequency. For the continuous and discrete numerical variables, we calculated the average, standard deviation, median, and variation. We applied the Cronbach alpha coefficient to the construct "Professional and patient safety" and to the HSOPSC instrument to verify the data reliability and intern consistency, establishing as evidence of satisfactory internal consistency values superior to 0,70.
The association of COVID-19 infection between variables: sociodemographic characteristics, professionals and the construct "Professional and patient safety" utilized Pearson's chi-squared test or Fisher's exact test. In the identification of the correlation between the HSOPSC dimensions and the "Professional and patient safety", we applied the Kendall correlation coefficient.
We considered α de 5% for all analysis.
Research demonstrates that higher exposure to labor risks is due to prolonged contact time with infected patients that need frequent interventions (13) .
The findings show that the working time in the unit was associated with COVID-19 infection and most professionals (89.77%) worked between 20 to 39 weeks hours only in one hospital (62.52%). The pandemic demanded a great volume of professionals as a working force, aiming to provide the challenges of the overload of highly complex care activities directed to critical patient care and in extreme vulnerability situations (14) .

Given the new challenges, a study carried out in
Pakistan with nursing professionals carried out educational interventions and learning through WhatsApp, and the results showed that the group participants reported significant improvement in the learning for "infections prevention and control", "knowledge COVID-19", as well as "leadership and communication" (16) . Moreover, in this same study, we verified that nursing professionals need longer periods of training and support for continuous learning and not only training restricted to hours or a few days (16) .
An investigation carried out with 2,707 professionals from 60 countries highlighted that the excessive training demanded in care during the pandemic influenced professional exhaustion, besides the exposure during patient care to COVID-19 and life prioritization; however, the use of PPE positively contributed to minimizing the burnout symptoms (17) . It is important to highlight that the institutional psychological support to the collaborators during the stress confrontation and emotional support during the pandemic were associated with better teamwork, a safe work environment, job satisfaction and job conditions and stress recognition (7) .
During the COVID-19 pandemic, the managers  (3,(18)(19) . The management during the peak of service and the necessity of allocating resources to guarantee the hope and well-being of the health professional are essential attributes to balance the patients' demands in the ICU and the maintenance of the worker's health status (3,(18)(19) .  (8,(20)(21)(22)(23)(24) .
The pandemic brought grave consequences that will